We all experience variations in mood, activity, and energy. For some people, these variations are so extreme that they become dysfunctional. Psychiatry is the discipline that has paid most attention to these extreme states, so they are typically framed in medical terms. For about 30 years now, they have been given the name bipolar disorders.
The aim of this blog is to discuss bipolar disorders in all their complexity. A good place to start is with the intriguing state known as hypomania.
What is Hypomania?
The American Psychiatric Association’s DSM—the manual of mental disorders—defines hypomania as a period of at least four days with marked changes in mood, activity, and energy. The symptoms of hypomania vary, but often include increased self-esteem, decreased need for sleep, and risky behaviour such as spending sprees or sexual promiscuity.
People who experience hypomania often describe it as a state where they feel, and sometimes objectively are, more productive and creative than usual. Hypomania, therefore, has a lot in common with normal states we might characterise as “hyper”—passionate love, the days after final exams, or that first weekend in Rio.
It is interesting to unpack how DSM (currently in its 5th edition, DSM-5) handles the blurry distinction between this euphoric hypomania and normal positive mood states. On one hand, hypomania must be out of character for the person, with the changes observable by others. On the other hand, DSM notes that hypomania does not impair functioning—your friends may notice the change, but it’s not getting you into any trouble.
Hypomania literally means “under mania,” and it contrasts with more severe changes in mood, activity, and energy that we’d see in a full-blown manic episode. Mania is an obviously abnormal state, often presenting with psychotic symptoms (hallucinations and/or delusions) or requiring hospitalisation.
A single manic episode leads to the diagnosis of bipolar disorder Type I (bipolar I), while DSM says hypomania alone does not constitute a mental disorder. You can meet all the criteria for hypomania in DSM, and not warrant any diagnosis.
So Why is Hypomania Mentioned in DSM at All?
Hypomania appears in DSM because it is an essential part of the diagnosis of bipolar disorder Type II (bipolar II). Bipolar II is diagnosed when a person has a history of both hypomania and at least one major depressive episode. DSM tells us that while hypomania alone isn’t a problem, hypomania and depression in the same person constitutes a diagnosable mental disorder potentially requiring treatment.
One way to understand DSM’s position is to consider that bipolar II refers to a somewhat unusual personality type. People prone to depression tend to be high on neuroticism and low on extraversion—and this personality profile is not one that is predisposed to four days of partying in Rio.
We used to think that bipolar II was less impairing than bipolar I because people with bipolar II don’t experience full-blown manic episodes. We now know that people with bipolar II spend some 50 percent of their days depressed, that their quality of life is severely impacted, and that suicide rates among this group are very high.
For people with bipolar II, hypomania is a double-edged sword. On one hand, hypomania can feel like a relief from chronic depression, and provide a window of energy to “catch up” with life goals. On the other, hypomania can precede depression, as well as magnify the mood swings that are so damaging to people’s work, relationships, and self-esteem. Hypomania is also not purely positive—people often experience irritability and even depressive symptoms within a hypomanic episode.
Hypomania is Clinically Important
In 2010, a coroner’s inquest was conducted into the suicide of Charmaine Dragun, an Australian TV newsreader. The inquest highlights the clinical importance of hypomania as part of the bipolar II diagnosis.
The coroner decided that Dragun’s doctor and psychologist were partly responsible for Ms. Dragun’s death because they had misdiagnosed her as suffering from depression. Dragun had presented for help with depression, and the health professionals did not ask about—and so did not hear about—her past history of hypomania. Had they identified hypomania, they would have arrived at the correct diagnosis of bipolar II. Dragun would likely have been prescribed mood-stabilising medication, increased suicide risk would have been recognised, and her death may have been prevented.
The coroner’s inquest led to a recommendation that anyone presenting with depressive symptoms should be systematically queried about a past history of hypomania. Patients are unlikely to spontaneously report past hypomania because it is often experienced as positive and productive—and therefore irrelevant to the person’s seeking help for depression. Indeed, the failure to identify past hypomanic episodes amongst people presenting for depression treatment is one of the primary reasons that a correct diagnosis of bipolar disorder is often delayed eight to 10 years after symptoms first appear.
Nature Is Complicated—Human Nature Even More So
A number of Psychology Today bloggers speak insightfully about their lived experience of bipolar disorders. My blog aims to complement those personal stories by providing updates on the clinical science of bipolar disorders.
Hypomania is an important feature of bipolar disorders, as it highlights the fuzzy line between normal positive experiences and patterns of variation that require treatment. The state of hypomania also encourages us to think about the strengths (e.g., creativity) and weaknesses (relationship problems) that come with a bipolar disorder diagnosis, and the challenges of managing mood shifts (“Is this happiness normal?”). These topics will be the focus of future posts.